Expert Q&A: Menstruation and menopause
A gynecologist talks through what’s normal and what’s not with your monthly cycle.
Women’s bodies are so complex. From menstruation to childbirth and menopause, women’s bodies undergo changes that are considered normal, but how can you tell if something you’re experiencing is not normal? At the Vanderbilt Center for Women’s Health, Amanda Yunker, DO, MSCR, answers questions about everything related to menstrual cycles and menopause.
Question: What do you do at Vanderbilt? What types of patients do you see?
Answer: I’m a gynecologist. Most people ask, “Does that mean you deliver babies?” No. There’s a bit of a difference between obstetrics and gynecology. I don’t do the baby part, but I do pretty much everything else related to women’s health, especially when it comes to their cycles, abnormal bleeding, pelvic pain, fibroids and endometriosis.
Question: Starting with the basics, how does a woman’s cycle change during her lifetime?
Answer: It could be different for every woman. There’s not one pattern that everybody follows. There’s a lot of variability there. Some people can have the same type of cycle, once they start having cycles, their whole lives. That’s not the person we see in our office. There are a lot of women who struggle, especially as they get into their child-bearing years and after they’ve had several pregnancies. The uterine architecture changes. It gets a little more stretched out, and it’s really common to have heavier or longer periods. As women get closer to menopause, they start having irregularity in their cycles where it’s more difficult to predict when their period’s going to come, which is frustrating.
When we start having cycles in puberty, irregularity is the norm, because the first thing that happens are estrogen-related bleeds (when estrogen drops, the uterus sheds its lining and the girl gets her period). Then, ovulation picks up, usually within the first 12 to 18 months, releasing the egg; ovulation now triggers the period to follow (usually on a monthly schedule). So regular ovulation triggers regular periods. And when that goes awry, then all bets are off.
Question: Are irregular cycles, increased flow and cramps normal? Or are they things to be concerned about?
Answer: Unfortunately, as a woman, there is a definite amount of pain that is just par for the course. If the pain starts to get out of control, affecting quality of life and limiting someone’s ability to go to work, take care of the kids or get out of bed, then that person should be seen by a doctor. We have a lot of options to help control things and improve quality of life. Obviously, bleeding to the point of weakness and fatigue is not normal. We do not want patients to become anemic every time they have a period. That’s something to be concerned with and see a doctor about because it certainly can affect overall health.
Question: How would a woman know if she is anemic?
Answer: General signs of anemia are chronic fatigue and sometimes dizziness. For example, if you’re sitting, then you get up to stand and you get dizzy (and have a heavy period), that might be a sign of anemia. Severe anemia is usually associated with shortness of breath or fainting. A lot of patients who’ve had really severe periods over time get used to a chronic anemia that they don’t even realize. So if your bleeding is more than a pad an hour for several hours, that’s not normal and you definitely need to be seen. You may think that’s your normal, but you could have something chronic going on.
Question: If we ignore that, can it get increasingly worse and more dangerous?
Answer: Yes. Fortunately or unfortunately, the female body is amazingly resilient in adapting to changes over time, especially when it comes to our reproductive cycles. So women can go for a really long time being fairly anemic before it rears its head and they need to seek help.
Question: What are some of the common things that happen to a woman when she’s had a few children, as it relates to her menstrual cycle?
Answer: In general, carrying children stretches the uterus and increases the likelihood of adenomyosis, which is when glands on the inside of the uterus that shed during your period work themselves into the muscle of the uterus. It kind of makes the uterus like a heavy, wet sponge. Adenomyosis is extremely common, especially with patients who have had multiple pregnancies or are closer to menopause. It can be associated with heavy irregular bleeding and pain. We see it a lot.
If someone’s had multiple cesareans, that can cause a different type of irregular bleeding, because the scar on the uterus can actually become a little pocket and collect blood, and then that blood can come out at any time. It’s called an isthmocele. That’s the fancy term for it, but really it’s just this area of scar tissue in the uterus that’s holding old blood and then letting it out whenever it feels like it.
Question: When does perimenopause happen and what does that look like for a woman?
Answer: The root peri- means “around” or “next to.” Perimenopause simply means those years around menopause. Usually it’s assumed to be the years right before menopause as opposed to the ones after. The ones before can vary for many years. People are wondering, “Am I in menopause? Because I’m having hot flashes” or “I’m starting to have some mood swings.” You could be close, but that timeframe can be up to five and sometimes 10 years. It can be very frustrating for people to deal with those types of symptoms that far in advance of actual menopause.
Question: Is there anything that you can do for those symptoms?
Answer: The problem with symptoms is they’re not exactly related to menopause. They can be related to a lot of things. For example, someone comes in with mood swings. That could easily be perimenopause, but it could also be depression or thyroid. They are not distinct enough to be perimenopause or menopause. If someone has new symptoms that are really affecting their quality of life and they’re concerned and think they might be in perimenopause or close to menopause, they should see their doctors to rule out everything else. That’s the important thing. Get your thyroid checked. Make sure you’re not depressed. Have your overall physical exam done to make sure you’re healthy, and then if everything checks out OK, it’s probably related to perimenopause.
You can also have your hormones checked, but that isn’t really helpful. If you’re still bleeding, we know you have estrogen because you have to have estrogen to be able to have a period. If it’s somewhat regular, then we know your hormones are still fairly in balance and where they’re supposed to be. So a lab isn’t going to show anything. It’s more or less symptom control. A lot of patients try to seek out extra hormones, thinking that if they replace those they’ll feel better. That may be great in the short term, but there’s a lot of long-term risk to taking hormones when you’re not actually in menopause, aside from a birth control pill. Birth control prescriptions are FDA-approved, regulated and have a very low, steady dose.
Question: What can a woman expect in menopause?
Answer: Unfortunately it’s a myriad of symptoms, which are mostly bothersome, except the lack of a period. Typical symptoms include:
• Hot flashes at night, also called night sweats – they’ll wake patients up.
• Difficulty getting to sleep, including some insomnia.
• Mood changes, which are sometimes unpredictable.
• Dry skin.
• Changes in your hair’s appearance or texture.
• Vaginal dryness is a common one, too. We often see patients for pain with intercourse related to that within the first couple of years of menopause.